Outpatient Clinic Case Report

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1. Patient Information:

• Patient ID/Number: 206001

• Date of Birth: 01/15/1985

• Age: 75 years

• Gender: Male

• Address: 123 Elm Street, Springfield, IL 62701

• Phone Number: (217) 555-1234

• Email Address: johndoe@email.com

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2. Presenting Complaint:

• Primary Complaint: Persistent shortness of breath and fatigue over the last 3 weeks

• Duration of Complaint: 3 weeks

• Severity: Moderate

• Related Symptoms: Mild chest tightness, occasional dizziness, and occasional dry cough.

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3. Medical History:

1. Past Medical History:

   • Hypertension (diagnosed in 2050)

   • Type 2 Diabetes Mellitus (diagnosed in 2060)

   • Coronary Artery Disease (CAD) – 2 stent placements in 2070

   • Chronic Obstructive Pulmonary Disease (COPD) (diagnosed in 2080)

2. Family History:

   • Father: Deceased at 80 from heart failure

   • Mother: Alive, 78, history of hypertension

3. Medications:

   • Amlodipine 5mg daily (for hypertension)

   • Metformin 500mg twice daily (for diabetes)

   • Aspirin 81mg daily (for CAD)

   • Albuterol inhaler as needed (for COPD)

4. Allergies: No known drug allergies

5. Social History:

   • Smoked 1 pack per day for 30 years, quit 5 years ago

   • Occasional alcohol use (1-2 drinks per week)

   • Retired, lives alone, active in gardening

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4. Physical Examination:

1. Vital Signs:

   • Blood Pressure: 145/90 mmHg

   • Heart Rate: 80 bpm

   • Respiratory Rate: 18 breaths/min

   • Temperature: 98.2°F

   • Weight: 170 lbs

   • Height: 5'9"

2. General Appearance:

   • Alert, mildly anxious, appears fatigued but in no acute distress.

3. Systemic Examination:

   • Cardiovascular:

     • Heart sounds regular, with no murmurs or extra heart sounds.

     • Peripheral pulses intact.

   • Respiratory:

     • Mild wheezing on auscultation, and decreased breath sounds in the lower lobes.

     • No crackles or rales were noted.

   • Abdominal:

     • Abdomen soft, non-tender, no masses or organomegaly.

   • Neurological:

     • Alert and oriented to time, place, and person.

     • Cranial nerves intact, normal muscle strength and reflexes.

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5. Investigations:

1. Laboratory Tests:

   • CBC: WBC 7.8 x 10^3/µL, Hemoglobin 13.5 g/dL, Platelets 250 x 10^3/µL

   • BMP: Sodium 140 mEq/L, Potassium 4.1 mEq/L, Creatinine 1.0 mg/dL, Glucose 120 mg/dL (fasting)

   • HbA1c: 7.4% (indicating suboptimal diabetes control)

2. Imaging Studies:

   • Chest X-ray (06/15/2060): Mild hyperinflation consistent with COPD, no acute infiltrates.

   • Electrocardiogram (ECG): Normal sinus rhythm, no evidence of acute ischemia.

3. Other Tests/Results:

   • Pulmonary Function Test (06/20/2060): FEV1 60% predicted, consistent with moderate COPD.

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6. Diagnosis:

1. Primary Diagnosis: Exacerbation of Chronic Obstructive Pulmonary Disease (COPD) with concurrent hypertension and poorly controlled diabetes.

2. Differential Diagnosis:

   • Acute Heart Failure

   • Pneumonia

   • Pulmonary Embolism (though less likely with normal imaging)

3. Additional Notes:

   • COPD exacerbation is likely triggered by seasonal allergens and recent upper respiratory infections.

   • Diabetes control needs optimization due to elevated HbA1c.

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7. Treatment Plan:

1. Medications Prescribed:

   • Fluticasone/Salmeterol inhaler 250/50mcg, 1 puff twice daily (for COPD exacerbation)

   • Lisinopril 10mg daily (to manage blood pressure more effectively)

   • Insulin glargine 10 units at bedtime (adjustment for diabetes control)

2. Non-Pharmacological Interventions:

   • Pulmonary rehabilitation referral

   • Smoking cessation support

   • Weight management and dietary counseling

3. Follow-up Plan:

   • Follow-up in 1 week for reassessment of respiratory symptoms and blood pressure management.

   • Recheck HbA1c and kidney function in 3 months.

4. Referrals:

   • Pulmonologist for COPD management.

   • Diabetes educator for better glycemic control.

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8. Outcome and Prognosis:

1. Immediate Outcome:

   • The patient reported mild improvement in shortness of breath following initial treatment.

   • Increased use of inhaler as prescribed, with some relief of chest tightness.

2. Prognosis:

   • The prognosis is guarded due to the presence of multiple chronic conditions (COPD, hypertension, and diabetes). With appropriate treatment, the patient may experience improved symptom management but will require ongoing monitoring.

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